Providing Psychotherapy for the Poor

IT HAD BEEN FOUR YEARS since 13-year-old Mohamed Abdul escaped civil war in Somalia, but he still had nightmares and flashbacks. When he was nine years old, a crowd fleeing a street shooting trampled him, putting him in the hos­pital for two weeks. A month later he saw the aftermath of an apparent massacre: about 20 corpses floating in the ocean. Soon after, militia-men shot him in the leg, knocked him unconscious, then raped his best friend, a girl named Halimo.

Recovering in the hospital, Abdul (not his real name) was overwhelmed by fear—and guilt, for not having helped Halimo. He felt unprovoked fury: he mistook people he knew well for the rapist and threatened to kill them. A few months later Abdul fled his homeland and landed in the Nakivale refugee settlement in Uganda. “I felt as if there were two personalities living inside me,” he said at the time. “One was smart and kind and normal; the other one was crazy and violent.”

Abdul had post-traumatic stress disorder (PTSD), an ailment characterized by fear, hyperarousal and vivid replays of the traumatic event. Fortunately, this refugee camp had an extraordinary resource. Psychologist Frank Neuner of Bielefeld University in Germany was offering “narrative exposure therapy” to its 14,400 Africans, mostly Rwandans. The approach coaxes trauma survivors to assimilate their troubling memories into their life stories and thereby regain some emotional balance.

After four 60- to 90-minute therapy sessions, Abdul’s flashbacks and nightmares disappeared; he was still easily startled but no longer felt out of control. His doctors deemed him “cured.”

Researchers and aid workers have historically overlooked mental health in developing countries, focusing instead on issues such as malnutrition, disease and high infant mortality, but that is changing. “What’s changed in the past 10 years is the realization that mental health is not separate from general health,” explains child psychiatrist Atif Rahman of the University of Liverpool in England.

Recent psychotherapy trials have achieved remarkable success in improving the lives of war survivors such as Abdul, poor mothers with postpartum depression and others victimized by the stresses of extreme poverty. The keys to a workable program for the impoverished include training ordinary citizens to be counselors and, in some cases, disguising the remedy as something other than a fix for emotional troubles.

Treating Trauma
Although many people think of mental illness as a plague of fast-paced modern life, some psychiatric ailments are actually more prevalent in the developing world, according to the World Health Organization. Of the several dozen wars and armed conflicts around the globe, nearly all are in developing countries, and this violence is leading to PTSD, which hinders recovery after the conflicts subside. Across South Asia, new mothers suffer from depression more frequently than they do in richer countries, according to a 2003 report by Rahman and his colleagues.

People in underprivileged nations also experience more severe economic stresses. “This pileup of adversities is associated with low mental health,” says sociologist Ronald Kessler of Harvard Medical School. For individuals living on the edge of survival, the economic ramifications of a mental illness can be especially devastating. When someone has a major mental illness, “you’ve lost their labor and their input,” notes mental health researcher Paul Bolton of Johns Hopkins University.

To make up for the deficit of mental health care professionals in the developing world, Neuner and his team recruited refugees from the camp. Anybody who could read, write and be empathetic was a candidate. Because nearly one third of the Rwandan refugees and half of the Somalis suffered from PTSD, many of the would-be counselors needed to be treated first.